Diabetes Management Plan
Note: The Diabetes Management Plan must remain with the Diabetes Register and the child at all times.
Child’s Name:
Date of Birth:
Doctors Name:
Doctors Phone:
Doctors Address:
Date of Plan:
Review Date:
Usual Diabetes Management
What time does your child require blood glucose testing?
1st Reading ____:____ am/pm
3rd Reading ____:____ am/pm
5th Reading ____:____ am/pm
2nd Reading ____:____ am/pm
4th Reading ____:____ am/pm
6th Reading ____:____ am/pm
Blood Glucose Monitoring
The minimum blood glucose level is:
mmol/L
The maximum blood glucose level is:
mmol/L
What actions are required if the blood glucose falls outside of the minimum and maximum ranges?
What time does your child require insulin injections?
am/pm
am/pm
am/pm
am/pm
am/pm
am/pm
Any other time, please specify:
am/pm
How do you recognise that your child is requiring attention to their Diabetes?
Does your child tell you when they are feeling unwell?
Yes
Excessive thirst/ hunger
Dizziness/ weakness
Change in behaviour
Sweating
Tiredness/ lethargic
Trembling/ shaking
Other, please specify:
DOCUMENT NUMBER & TITLE
NQS2 Diabetes Management Plan APPENDIX
POLICY OWNER
Stan Coulter, General Manager,
Governance and Risk
DATE PUBLISHED
30/10/2013
RECORD MANAGEMENT SCHEDULE
DOCUMENT VERSION
CONTENT OWNER
V6.0
Kylie Warren-Wright, National Health and
Safety Manager
REVISION DUE DATE
18/11/2015
Child Enrolment - C+3yrs
Ensure you are using the latest version of this policy. You can find it at
http://policies.goodstart.org.au/PoliciesandProcedures/NQS2%20Diabetes%20Management%20Plan%20APPENDIX.docx
Warning – uncontrolled when printed. This document is current at the time of printing and may be subject to change without notice.
No
Activities and Exercise
Are there any activities or exercise that your child can not participate in?
Yes
No
If yes, please provide details:
Does your child usually require any insulin before/after exercise or play?
Yes
No
If yes, please provide details:
Medication
Dose
Method
Frequency
Parent/Guardian Name:
Centre Director/Director in Development Name:
Signature:
Signature:
Date:
Date:
Note: Please also attach a copy of the Diabetes Management Plan from the doctor as well as step-by-step
instructions on completing the Blood Glucose Levels (BGL) testing and insulin administration (where insulin is
required), as well as a food plan/menu for the child.
DOCUMENT NUMBER & TITLE
NQS2 Diabetes Management Plan APPENDIX
POLICY OWNER
Stan Coulter, General Manager,
Governance and Risk
DATE PUBLISHED
30/10/2013
RECORD MANAGEMENT SCHEDULE
DOCUMENT VERSION
CONTENT OWNER
V6.0
Kylie Warren-Wright, National Health and
Safety Manager
REVISION DUE DATE
18/11/2015
Child Enrolment - C+3yrs
Ensure you are using the latest version of this policy. You can find it at
http://policies.goodstart.org.au/PoliciesandProcedures/NQS2%20Diabetes%20Management%20Plan%20APPENDIX.docx
Warning – uncontrolled when printed. This document is current at the time of printing and may be subject to change without notice.